In the addiction treatment field, when we refer to "steroid use," we are referring to those compounds known as anabolic steroids-those whose primary use is to cause skeletal muscle hyperplasia or enhancement and that are therefore sought after for the main purposes of muscle growth and physical performance. We distinguish anabolic steroids from corticosteroids and female gonadotrophic hormones; neither of which is found to be abused. Most steroids also have androgenic properties and thus are generally referred to as anabolic-androgenic steroids.

The use and misuse of steroids through the years are well documented by Kochakian (1990). In 1849, the use of steroids in male sexual development is documented, but it was not until 1930 that the active metabolite of testosterone-a drug named androsterone-was identified in urine. In the 1940s, synthetic testosterone was successfully synthesized in the laboratory with the goal of separating the anabolic from the androgenic effects. Although there was some success in this endeavor, even today, there continues to be androgenic effects in synthesized anabolic steroids. The misuse of anabolic steroids for weight lifters and bodybuilders has been identified since 1954, and their use has expanded to many professional sports. In 1984, the International Olympic Committee found that 50% of the athletes had urine screens that were positive for anabolic steroids. More recently, athletes continue to be stripped of their winning trophies and medals because of discovered steroid use for the purpose of enhancing performance. Because testing for steroids has become commonplace, other performance enhancers are being used such as erythropoietin, somatotropin, and thyroxine. Because these agents are naturally found in the body, it is difficult to determine whether these drugs are being misused. Identification of misuse can be determined utilizing carbon isotope mass spectrometry; however, this test may be too expensive for common use (Graham, Davies, Grace, Kicman, & Baker, 2008). In addition, drugs from other pharmacologic categories continue to be used to boost performance including certain opioids, clonidine, human chorionic gonadotropin, and gamma hydroxybutyrate, to name a few. Even veterinary products are used for potential enhancement effects. A variety of diuretics are used to increase clearance of these exogenous drugs from the body before drug testing.

The Internet is a common and well-known source to gain knowledge about these drugs, how to obtain them, how much to use, and how to avoid positivity in urine drug screens (Brennan, Kanayama, & Pope, 2013). As a result, we are seeing nonathlete adults and young boys illicitly obtaining and using steroids just to improve their physical appearance. Use in women does occur, but it appears to be a much smaller percentage than male use. However, in a study by Elliot, Cheong, Moe, and Goldberg (2007), over 5% of female high school students used anabolic steroids. Furthermore, steroid use in this population correlated with other unhealthy life choices including using tobacco, cannabis, and diet pills; carrying weapons; and having sexual relations before the age of 13 years. This group was also less likely to participate in team sports. Another interesting finding is, when well-known athletes are reported to have been using steroids, use among risky populations increases. Because there is a high percentage of athletes (professional and nonprofessional) who use products such as vitamins and protein supplements, Dunn, Mazanov, and Sitharthan (2009) suggest that use of such supplements is a natural gateway for future anabolic steroid use. The authors also found that, contrary to the preconceived notion that anabolic steroid users are a health-conscious group, there was a relatively high incidence (52%) of respondents who also used other illicit drugs. In fact, a study by Dodge and Hoagland (2011) reported a positive correlation with the use of other licit and illicit drugs such as alcohol, cocaine, painkillers, psychostimulants, ketamine, and other performance-enhancing agents.

Three distinct populations have been identified who abuse anabolic steroids: (a) those who use them to improve performance, (b) those who use them to improve appearance and gain some weight, and (c) those who use them to enhance aggression and fighting skills (Brower, 1989). Minor side effects are common and usually reversible. However, serious medical consequences and toxic reactions can occur, particularly involving endocrine function and hepatic, cardiovascular, and nervous systems. When a steroid user reports specific side effect presentations to the treatment provider, they generally do not reveal their history of steroid use, often leading to misdiagnoses. Because anabolic steroids exert an inhibitory action on the hypothalamic-pituitary axis, there is a decrease in testicular size and sperm count in men. In addition, because testosterone is metabolized to estradiol, the circulating estrogens cause feminizing physical effects such as gynecomastia. Other nontestosterone drugs generally do not cause these effects. An interesting observation is that steroids produced endogenously (such as in Cushing's syndrome) generally cause depressive presentations, whereas steroids taken exogenously cause a hypomanic or manic presentation. A presentation referred to as "roid rage" consists of verbal aggression, impulsiveness, and, sometimes, violent outbursts. Severity of symptoms generally correlates to severity of amount and chronicity of use. Steroid abusers with no record of antisocial behavior or violence have committed murders and other violent crimes. When steroids are stopped, the person can become depressed, anxious, and concerned about their bodies' physical state. Some similarities have been noted between steroid users' views of their muscles and the views of patients with anorexia nervosa about their bodies. They are usually preoccupied with their physical attributes and may rely excessively on these attributes for self-esteem.

The anabolic steroid addiction hypothesis was proposed over 25 years ago, yet there have been few empirical studies conducted to actually test it. Actually, steroid misuse does not follow the patterns typically seen with other drugs of abuse such as heroin, cocaine, alcohol, and so forth. To the contrary, anabolic steroids are usually taken once per week, and the effects are sufficiently delayed after self-administration. This decreases the drug's reinforcing efficacy and drug-seeking behaviors as compared with other drugs. There have been a few anecdotal reports that high doses of anabolic steroids can elevate mood, but no controlled studies have shown any degree of euphoria.

A study was done by Peters and Wood (2005), which concluded that anabolic steroids share neurotransmitter and receptor sites with opioids because steroid overdose produced symptoms resembling opioid overdose, using an animal model. This has not been further studied. There is also little evidence supporting tolerance development, and it is believed that escalating doses are taken to increase the magnitude of the desired effects rather than the result of developing tolerance.

The treatment goal for patients using anabolic steroids is abstinence. Physical withdrawal symptoms, if any, are not life threatening and do not ordinarily require pharmacotherapy. Should musculoskeletal pain or headaches occur, the use of a nonsteroidal anti-inflammatory drug may be indicated. Clinicians should be aware of the potential for the development of anabolic steroid-induced mood disorders or anabolic steroid-induced psychotic disorder.

A precursor hormone for both estrogens and androgens, called dehydroepiandrosterone, is available as an over-the-counter nutraceutical and sold under the name "DHEA." There have been marketing efforts to increase interest in DHEA for improving cognition, depression, sex drive, and general well-being, especially in geriatric patients. However, few controlled studies on the safety and efficacy have been done. DHEA in dosages of 50-100 mg per day are believed to increase the sense of physical and social well-being. Androgenic effects include irreversible hirsutism, hair loss, voice deepening, and other undesirable sequelae. In addition, DHEA has at least a theoretical potential for enhancing tumor growth in persons with latent hormone-sensitive malignancies, such as prostate, cervical, and breast cancer.

Obviously, in light of the current environment of experimentation, impulsiveness, and the need for immediate gratification among the emerging young adult population, there needs to be more emphasis on education and research into the consequences of anabolic steroid use. For Popeye, was spinach a euphemistic way of meaning "steroid?" I hope not.

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